NRV 51 Diabetes Mellitus Iclicker Question Diabetes mellitus occurs when either the body becomes resistant to insulin

or this organ does not make enough insulin: *Pituitary *Pancreas *Spleen Iclicker Question The human body requires which of the following to metabolize glucose? *Pancrease *Gastrin * Lipase * Insulin Review of Anatomy & Physiology of the Pancreas *MS page 873 & 875 877 & 878 *Acini digestive enzymes *Islets Insulin & Glucagon *Duct Bicarbonate Pancreatic Secretions

Actions of Insulin to Control Glucose Levels *Major stimulus for synthesis and secretion of insulin is elevated BG. *Insulin increases cell membranes permeability to glucose. After it is in the cell, glucose is used in cellular respiration to produce energy. *Insulin stimulates the liver to convert extra glucose into glycogen (glycogenesis), and helps the liver and muscles to store glycogen. Glycogen is stored as body sugar, commonly referred to as animal starch. *Insulin increases the transfer of amino acids across muscle membranes for synthesis into proteins. *Insulin speed fatty acid synthesis (lipogenesis) for fat storage. *Insulin slows glycogenolysis (glycogen breakdown) and gluconeogenesis (formation of glucose from non-carbohydrate sources). *MS page 876 877 & 878 Insulin

Blood glucose regulation * BG insulin secretion glucose into cells Effects of Aging on Pancreas

*MS page 876

Diabetes Mellitus *American Diabetes Association (ADA) Definition: *A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels. *Malfunction of beta cells of pancreas. Hyperglycemia results from Defects in: *Insulin secretion or *Insulin action or *Both Incidence of DM *7 % of population in US *21 million known cases of DM in US *6 million do not know have Diabetes Mellitus in US *No age group exempt *90 95% of known cases are adults *6th leading cause of death in US *Big cost to health care system no cure for DM *Major reason for hospitalization, surgery and community health care *Dialysis Centers DM leading Dx along with HTN Terms *Family Practice Doctor MD *Internist (Internal Medicine) MD *Endocrinologist - MD *Diabetologist - MD *Certified Diabetic Educator (CDE) - RN *Hyperglycemia *Hypoglycemia Factors Affecting Blood Sugar *Raises Hyperglycemia *Food *Stress *Growth *Medications *Thiazide Diuretics *Furosemide (Lasix) *Prednisone *BCP *Phenytoin (Dilantin) *Menstrual Cycle *Lowers Hypoglycemia *Insulin *Oral Diabetic Agents *Exercise *Alcohol

Risk Factors for DM *Diet *Obesity *Lack of exercise *Heredity - genetics *Age *Stress emotional or physical *Race MS page 910 *Pregnancy *Recent Infection mumps or coxsackie virus *Autoimmune reaction AHA Metabolic Syndrome Risk for CV Disease *3 or more risk factors present *MS page 410 Box 17-1 & pages 930 931 & ____ *MS page 910 *Type 1 *Type 2 *Pre-Diabetes or Impaired glucose tolerance *Gestational Diabetes *Statistical Risk of Diabetes Types of DM

Type 1 Diabetes Mellitus *Formerly known as Insulin Dependent DM IDDM and Juvenile Diabetes or Juvenile-Onset *Bodys immune system destroys beta cells *5 - 10% of all DM cases *More likely to appear early in life *Hereditary *Virus & Environment *Nick Jonas Type 1 Diabetic http://www.zimbio.com/pictures/Mu6wvxGVFZy/Nick+Jonas+Discusses+Juvenile+Diabet es+National/4g6iXLaji88/Nick+Jonas Type 1 Diabetes Mellitus *Autoimmune *Must take insulin for rest of life *Prone to Ketosis and Diabetic Ketoacidosis (DKA) *Developmental issues may complicate self-care Classic symptoms of Type 1 DM *MS page 910 *3 Polys *Polydipsia *Polyuria *Polyphagia *Weight loss Other S/S *Fatigue & weakness *Irritability *N/V *Infections Type 2 Diabetes Mellitus

*Formerly known as Non-Insulin Dependent DM NIDDM and Adult-Onset or Maturity-Onset Diabetes *Begins with insulin resistance body can not use insulin *90-95% of all known cases of DM *Obesity, Sedentary Lifestyle, Age, Ethnicity, Heredity *Not prone to Diabetic Ketoacidosis (DKA) Type 2 Prevalence *Generally develops later in life, but in children due to obesity *Greater incidence *Native Americans *Hispanic *African Americans *Asian Americans including Pacific Islanders

*Nell Carter of Give Me a Break dies at age 54 of CHD complicated by her Type 2 DM http://images.search.yahoo.com/images/view?back=http%3A%2F %2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Dcelebrites%2Bwith %2Btype%2B2%2Bdiabetes%26b%3D43%26ni%3D21%26ei%3Dutf-8%26y %3DSearch%26xargs%3D0%26pstart%3D1%26fr%3Dyfp-t-701s&w=265&h=400&imgurl=cdn.blisstree.com%2Ffiles%2F2010%2F09%2F1741848265x400.jpg&rurl=http%3A%2F%2Fblisstree.com%2Flive%2F5-celebrities-who-diedtoo-young-and-overweight-yes-a-few-also-used-drugs%2Fgallery-page %2F1%2F&size=27KB&name=... +by+type+2+di...&p=celebrites+with+type+2+diabetes&oid=b7de1bae3e577c493245f8486 eae3f26&fr2=&spell_query=celebrities+with+type+2+diabetes&no=62&tt=649&b=43&ni =21&sigr=13jjj83ee&sigi=11jvfbr6f&sigb=14bmm2pn5#FCar=b7de1bae3e577c493245f84 86eae3f26 Type 2 Diabetes Mellitus *Hyperlipidemia is often present *Hypertension is often present *Weight loss and exercise will improve control of blood sugar, blood pressure, and lipid profile *Oral hypoglycemia agents (OHAs) often effective *May have to take insulin Comparison of Type 1 vs.. Type 2 *MS page 910 Pre-Diabetes or Impaired Glucose Tolerance *MS page 910 & LAB pages ____ *Blood glucose > normal, but < criteria for diagnosis of DM *FBS > 110, but < 126 mg/dL *OGTT > 140, but < 200 mg/dL after 2 hours *Risk for developing Type 2 DM, ASHD and CV Diseases. *Weight loss and physical activity can prevent DM Gestational Diabetes *MS page 910 *2 - 3rd trimester of pregnancy *Disappears after pregnancy *20 - 50% chance Type 2 DM within 5 10 years

Iclicker Question Type 1 Diabetes Mellitus is also known as: *NIDDM *IDDM *Impaired glucose tolerance *Gestational DM Iclicker Question Type 2 Diabetes Mellitus is also known as: *NIDDM *IDDM *Impaired glucose tolerance *Gestational DM Iclicker Question Classic symptoms of Type 1 Diabetes Mellitus include: (Select all that apply.) *Polyuria *Polydipsia *Polyphagia *Polyphasia Iclicker Question Other symptoms of Diabetes Mellitus Type 1 and Type 2 include(s): (Select all that apply.) *Weight gain or loss *Fatigue *Blurred vision *Infections Diagnostic Blood Tests for Diagnosis of DM *MS page 882 and LAB page _____ *Fasting Blood Sugar/Glucose (FBS) *2 Hour Post-Prandial Blood Sugar/Glucose (2-Hour PPG) *Oral Glucose Tolerance Test (OGTT) *Blood Diagnostic Tests to Monitor DM *Glycosylated Hemoglobin (HbA1C) *Fructosamine Assay *Urine *Urine for Ketone Bodies *Urine for Microalbumin (MA) Venous Blood (Serum) *Fasting Blood Sugar (FBS) * MS page 882 & LAB page _____ *aka Fasting Plasma Glucose (FPG) *Normal = 70 110 (or 115 mg/dL MS text)

*Fast for 8 hours before test *Elderly - after age 50 *1 mg per decade of age *Random (Casual) blood glucose *Normal < 200 mg/dL *Anytime of day Fingerstick Blood Glucose/Sugar *FSBS or FSBG *Normal = 70 110 or 115 mg/dL *DM Pre-diabetic = > 110, but < 126 mg/dL Two hour Post Prandial (2-Hour PPG) *MS page 882 or LAB page _____ *Blood sample taken 2 hours after high (75 Grams) CHO meal then nothing else till blood drawn *Usually FBS done before meal Normally in non-diabetics blood glucose returns to normal level 2 hours after a meal. Diabetics does not return to normal in two hours. *Normal = < 126 (MS) or < 140 (LAB) mg/dL *MS - Elderly 5 10 mg/dL with age *LAB * 50 60 y/o = < 150 mg/dL *60 + = <160 mg/dL Oral Glucose Tolerance Test (OGTT) *MS page 882 or LAB page _____ *Drink concentrated glucose liquid (75 Grams) *Blood & urine specimens at: *Fasting *30 minutes *1,2 ,3 and sometimes 4 hours *DM = return to normal slowly & urine + for glucose *> 200 mg/dL at 2 hours *Gestational DM LAB page 277 Diabetes is Diagnosed when *MS page 881 and LAB page ____ *Any one/two of these: *Clinical symptoms three polys plus random (casual) FBS 200 mg/dL * FBS of > 126 mg/dL on > one occassion *OGTT > 200 mg/dL after 2 hours of 75 Grams of glucose Glycosylated Hemoglobin (HbA1c) *MS page 882 & LAB page ____ *Used to monitor DM and determine if client in control & following medical regimen in past 2 -3 months (span of RBC) *Attached to Hemoglobin so cant lie! *No fasting *Test done periodically *Normal = 3.9/4 5.2/5.9 % range *Goal - DM < 7 % (150 mg/dL of glucose) *Control MS page 882

Fructosamine Assay *MS page 882 *Used to monitor DM and determine if client in control & following medical regimen in past 2 -3 weeks *Sugar attached to albumin - shorter time frame *Fasting not necessary *Less influenced by age than HbA1c Urine for Ketones *MS page 882 and LAB page ____ *Part of Urinalysis *Also part of Urine for S&A or Keto-Diastix *Check when FSBS is > 240 mg/dL = DKA *Looking for ketones (acetone) = ketonuria *Fresh urine sample Urine for Microalbumin (MA) *Indicator of complications of DM Kidneys, heart, small blood vessels) *First indicator of renal disease *For Diabetic - early indicator of nephropathy, CVD, HTN, retinopathy & end-stage renal disease *Recommended all diabetics > 12 y/o yearly microalbumin urine test *Normal = < 2 mg/dL *Calculated with creatinine levels due to hydration status effect LAB page ___ Iclicker Question The normal fasting blood sugar (FBS) is: *70 110 mg/dL *120 200 mg/dL *220 240 mg/dL *300 400 mg/dL Iclicker Question With an Oral Glucose Tolerance Test, it is expected that the blood glucose level would return to a normal (fasting level) in what time period after the ingestion of an oral glucose solution? *2 *3 *4 *5 hours hours hours hours

Iclicker Question With a diabetic client, a urine for ketones (acetone) test should be done when the blood glucose level is consistently above: *120 *180 *210 *240

Iclicker Question A male client who was recently diagnosed with diabetes mellitus visits his physician for a followup exam. His physician wants to assess how he is adjusting to his new diet and medication use. The laboratory study his doctor would order to reflect the patients average blood glucose level over the past two months is called a(an): *Fasting Blood Sugar (FBS) *Oral Glucose Tolerance Test (OGTT) * Glycosylated Hemoglobin (HbA1c) *2 hour Postprandial Blood Glucose (2 Hr PP) Complications of Diabetes Acute Metabolic Complications

*Hyperglycemia *Hypoglycemia

Hyperglycemia Causes *Too little insulin or diabetes medication *Too much carbohydrate *Illness, especially infection *Stress *Meds steroids, diuretics, etc. S/S Hyperglycemia *Glycosuria *Polyuria *Anorexia, nausea, vomiting [may be hungry 1st] *Headache, vision changes double vision *Flushed, dry skin *Altered level of consciousness [ALOC] Treatment of Hyperglycemia *Type 1 Insulin *Type 2 Diet & exercise, if necessary OHAs *What to do when traveling MS page 928 Diabetic Ketoacidosis (DKA) *Complication of hyperglycemia *Severe, hard to control diabetics - brittle *Or undiagnosed stress, infection or noncompliance *S & S - MS page 926

*Kussmauls Respirations
http://coursewareobjects.elsevier.com/objects/elr/Potter/fundamentals7e/animations/fla shpage.html?swf=seidel5e_v1/ch12/anim/12-14.swf *BS > 240 mg/dL *Glycosuria *Ketonuria DKA Treatment *Reduce blood glucose *IV insulin regular RN or MD *Correct fluid & electrolyte imbalance *IV fluid & IV Potassium

*Clear urine & blood of ketones *IV glucose, IV potassium DKA Nursing Care *VS *Monitor IV fluids *I&O * electrolytes *Cardiac monitor arrhythmias *Monitor blood sugars * Urine for ketones *Teach prevention MS page 926 *What to do on Sick Days- MS page 927 Hypoglycemia *BG < 70 mg. / dL *DM cause = too much insulin for amount of glucose present *Severe hypoglycemia can cause coma, death Hypoglycemia can also occur when *Too little food is taken *Insulin or OHA medication is @ its peak of action *Alcohol is taken by persons on OHA meds. *Unusual amounts of exercise are done [exercise increases insulin action] S/S Hypoglycemia *Skin: cool, clammy, moist, pallor, sweating *C-V: inc. HR (palpitations) & inc. BP *Neuro: shaky, nervous, irritable, tremulousness, weakness *GI: Hunger *Eyes: Blurred vision *If untreated can progress to confusion, disorientation, ALOC Hypoglycemia Hypoglycemia Treatment *Prevention is best! If in doubt, treat for hypoglycemia! *Depends upon degree of hypoglycemia and LOC *Fast-acting carbohydrate [CHO] milk, crackers, OJ *15 Grams CHO every 15 minutes *Home Treatment MS page 914 *Longer-acting CHO when S/S improved peanut butter, cheese & crackers Fast-acting CHO for Hypoglycemia *120 ml. [4 oz.] orange juice *120 ml. regular soft drink *2 packets sugar or honey *Glucose tablets / gels *Buccal cavity Recheck blood glucose in 15 min.! Hypoglycemia Treatment when unable to give oral sugar *Intravenous dextrose [D50] *Glucagon [IV, IM, SQ]

After hypoglycemia is resolved *Pt. should eat a balanced meal *Situation should be analyzed, cause discovered. *Physician needs to be notified. Hypoglycemia vs. Hyperglycemia *PHARM page ____ Service Dogs for Diabetes (D4D) *http://dogs4diabetics.com/ *Can detect hypo and hyperglycemia *Signals owner minutes before *Can help avoid the peaks and valleys of glucose control *Prevent organ damage *A service dog dog gets trained, owner receives training also

*Girl with dog & history of DM - http://images.search.yahoo.com/images/view?back=http%3A

%2F%2Fimages.search.yahoo.com%2Fsearch%2Fimages%3Fp%3Ddogs %2B4%2Bdiabetes%26ei%3DUTF-8%26fr%3Dyfp-t-701-s%26fr2%3Dtabweb&w=928&h=960&imgurl=www.childrenwithdiabetes.com%2Fpeople%2Fimages %2FGillian2009crop.jpg&rurl=http%3A%2F%2Fwww.childrenwithdiabetes.com %2Fkids %2Fd_02_1ul.htm&size=1MB&name=have+been+to+dia...&p=dogs+4+diabetes&oid=33 17fe1de68ef9da7dac3e18c7dc3a5b&fr2=tabweb&no=9&tt=7440&sigr=11l0fno1b&sigi=11u0c3nkh&sigb=132ode14m Iclicker Question Hypoglycemia can be caused by: (Select all that apply.) *Administration of too much insulin *Excessive or too much exercise *Poor dietary intake *Alcohol Iclicker Question Which of the following statements is true of hyperglycemia? (Select all that apply.) *It can be caused by exercising more than usual by a person with Type 2 diabetics. *Symptoms include flushed, hot, dry skin along with altered LOC. *Giving too much insulin can lead to ketoacidosis in the hyperglycemic client. *An infection such as a urinary tract infection can cause hyperglycemia. Iclicker Question After administering treatment for hypoglycemia, the SVN should recheck the blood glucose: *After 15 minutes *After 30 minutes *After 1 hour *Before the next meal or at HS

Case Study # 1 Hypoglycemia A young female with no history of diabetes, but has a history of hypoglycemia went to school without eating breakfast. At 10 am during a difficult test, she became dizzy, light headed, shaky, weak and diaphoretic. *What lead to this hypoglycemic event? *What should this student do to treat this event? *What recommendations would you give this student to prevent this episode from recurring? *SBAR this situation. *Develop a concept map. Case Study # 2 Hyperglycemia A young female who is busy preparing for her wedding noticed that she has been losing weight. She is always hungry and thirsty. She drinks a lot of fluid and has to urinate frequently. She attributes all of these symptoms to stress. *Do you agree? *What could this person be experiencing? *What assessments are significant? *What nursing diagnoses apply to this person? *SBAR this situation. *Develop a concept map. Other Diabetes Complications

*Macrovascular *Microvascular

Macrovascular Complications Arterial Occlusive Diseases *Coronary artery disease [CAD] *Cerebrovascular Disease [CVA] *Peripheral Vascular Disease [Arteries = PAD] *Orthostatic hypotension rise slowly Microvascular Diseases *Retinopathy *Nephropathy *Neuropathies *Foot and Leg Problems Neuropathies *Sensorimotor *Autonomic Sensorimotor Neuorpathy *Most common in feet *Paresthesias *Burning *Decreased sensation *Gabapentin [NEURONTIN] = analgesic

Autonomic Neuropathy *Delayed gastric emptying *Metoclopramide [REGLAN] AC *Increases peristalsis *hypoglycemia unawareness *Impotence Nephropathy *UTIs *Urinary retention * End Stage Renal Disease (ESRD) * BUN & Creatinine and BP * Albuminuria *ACE inhibitors slow progression Diabetic Retinopathy blindness *Blood vessels rupture & leak scar tissues distorted vision blurred vision & visual acuity *ACE inhibitors dilate blood vessels - progression Infections *Glycosuria UTI *Poor wound healing Iclicker Question Complications that can occur with Diabetic who do not achieve tight control would include: (Select all that apply.) *Blindness due to diabetic retinopathy. *Edema due to kidney failure due to nephropathy. *Skin breakdown due to neuropathy and paresthesias. *Delayed gastric emptying requiring Reglan for treatment. *Hypertension due to ASHD as a result of hyperglycemia. Health Deviation Self-Care Requisites in Diabetes Goals of care *Promote optimal wellness *Support normalcy *development *lifestyle *Prevent complications Goals are best achieved when THE PATIENT is the one in charge M.D., Nurse, dietician, etc. are helpers! *Education *Diet *Activity *Medication *Monitoring 5 Aspects of Diabetes Management

Blood Sugar Control *Keeping blood sugar near normal [tight control] prevents or delays microvascular complications *Tight control requires excellent self-care *Tight control may not be appropriate where risk of hypoglycemia is high Tight Control Goals *Fasting Blood Glucose - 80-130 *Glycosylated Hemoglobin [HbA1C] - < 7% Diet Goals *Maintain blood sugars as near-normal as possible *Achieve optimal serum lipid levels *Provide needed calories & nutrients Special Goals - Type 2 *Keep BP WNL *Achieve desired lipid levels *Weight loss if appropriate Food Intake - Type 1 * Must be synchronized w/ insulin intake and exercise. *ADA diet 1800 cal ADA, 2400 cal ADA, etc. Food composition recommended *10 - 20 % calories from protein *< 10% calories from saturated fat *Insulin need determined by amount of CHO consumed *Complex CHOs preferred over simple *Alcohol in moderation Diet *Glycemic Index *CHO counting *Exchange List *Eat at same time each day *Eat foods from all food groups *Limit fat and sugar foods *Eat about the same amount each day *Use snacks to prevent low blood sugar *Plate Method *1/3 protein *1/3 starch *1/3 vegetable *plus fruit & beverage Exercise-Benefits *Improves insulin utilization *Improves blood lipids *Promotes weight loss *Increases sense of well-being

Exercise - Risks *Persons on insulin, sulfonylurea drugs *May cause hypoglycemia *May worsen hyperglycemia if insulin deficient Minimizing Exercise Risks *Type 1 - dont exercise if BG > 240, ketones in urine *Snack before, after if prolonged exercise *Insulin dose may be decreased *Check blood glucose before, during, after exercise Self-Monitoring of Blood Glucose [SMBG] *Monitors effectiveness of diet-exercise-medication program *Guides insulin administration *Recommended for most diabetics *Frequency QID or daily or weekly SMBG Timing *AC & HS most common, esp. if hospitalized, or on insulin or tight control *BID or daily for some *After meals to assess adequacy of insulin dose *Before, during & after exercise if on insulin or previous hypoglycemia occurrence w/ exercise *Any time S/S of hypo or hyperglycemia occur Hospitalized Diabetics *Often have higher than their usual blood sugars [stress of illness] *Pts. controlled on oral meds @ home may require insulin *Need for insulin may be temporary Diabetic Foot Problems-Causes *Neuropathy - loss of pain and pressure sensation *Poor circulation - impairs wound healing *Smoking much more dangerous to diabetics *Immunocompromised Diabetic Foot Problems-Prevention *MS page 927 *Inspection *Thorough drying after bathing *Lubrication *Podiatry for problems *Well-fitting closed-toes shoes *Dont go barefoot *Trim nails *Lambs wool for pressure relief *Exercise Recommended Health Screening *Dilated eye exam yearly *Test for microalbuminuria yearly *Blood lipid panel yearly *HbA1C every 3 months

Patient Education *Infection Control *Fluids *Eye Exams *Medications travel MS page 928 *Blood Glucose Monitoring *Medic Alert tags *Working with Elder Clients MS page 928 Patient Education - continued *American Diabetes Association *Diabetic Educator *Home Care Visits *Website

*American Diabetic Association - http://www.diabetes.org/ *Dogs 4 Diabetes - http://dogs4diabetics.com/

Diabetic Nursing Care Plan *MS page 923 - 925 Iclicker Question You are preparing to give a male client his insulins - Regular and NPH - one morning. His glucose level is 57mg/dL. He just drank some water. You would: *Administer both of his insulins, his breakfast tray is available. *Administer both of his insulins and bring him orange juice with extra sugar. *Hold his both of his insulins, give him orange juice and recheck his blood glucose. *Hold his NPH insulin, give him orange juice and recheck his blood glucose. *Give him an injection of Glucagon. Iclicker Question Patient teaching for a Diabetic client would include: (Select all that apply.) *Encouragement to get yearly eye exams. *Purchasing properly-fitted closed toes shoes. *Getting his/her blood pressure checked monthly. *Seeing a podiatrist for any foot problems. *Exercising at least 30 minutes daily. Case Study # 3 Diabetic Complications A young male who has had Type 1 DM since his teens presents with a microalbumin level of 10, an elevated BUN and creatinine, edema of the lower extremities and dyspnea on exertion (DOE). *What are your concerns re this client? *What questions would you ask this young man? *What other data would you like to know? *What recommendations do you have for this young man? *What patient teaching would be helpful?

DIABETIC DRUGS - Pharm Chapter ___ *Function *Allows glucose into cells *Allows glucose to enter liver *Prevents fat breakdown *Stores excess calories as fat *Must be taken daily *Cannot be taken orally *Inactivated by digestive enzymes *Must be given by injection *Someone must give injection *Abdomen *Rotate Sites MS page 917 *All Human insulin now *Used to have Beef or Pork *U100 (100 Units per 1 ml) *Syringe must match insulin U100 *Class: hormone *Actions: promotes cellular uptake of glucose thereby lowering BG *Indications: Type 1 DM, Type 2 DM where BG control cant be achieved w/ oral meds *Nursing: comes in different types, w/ different kinetics; exercise increases effect Insulin nursing: nursing: contd * BG before giving; S/S hypoglycemia; higher dose may be needed when pt. is ill or otherwise stressed; abdomen is preferred SQ injection site; rotate injection sites Insulin routes *Subcutaneous [SQ]-usually *Intranasal *Intravenous - when faster action is needed *RN or MD, not LVN Subcutaneous Sites *Abdomen - most consistent absorption *Arms *Legs *Rotation recommended to avoid lipoatrophy *Uncommon with human insulin Insulin Concentrations *U100 - 100 units / ml. usually *Use U-100 syringe *U 500 - 500 units / ml. *very insulin-resistant clients *use U-500 syringes Insulin Insulin

Insulin

*Orange cap *Marked in units *Flat top *1/2 ml most common size *Also comes in 1 ml, 1/3 ml, 1/4 ml

Insulin Syringes

INSULIN TYPES - KINETICS * Different insulins have different onsets, peaks, durations of action * MS page 915 *Bottles good for 30 days after opening *Room temperature unless used infrequently *Lantus no mix with other insulins in same syringe *Lantus once at day at night/bedtime Insulin / Meal Timing *Regular - 30 min. AC *Humalog - 5-10 min. AC Insulin & Sliding Scale *SMBG AC & HS *Dose based on blood sugar *Dose to cover hyperglycemia AND *Provide insulin for meal or snack to follow *Combining Insulins MS page 916 *Clear to cloudy Sliding Scale *Syllabus page *U100 Regular Insulin *Humalog some cases *Given AC & HS MS page 915 & Syllabus Insulin Mixtures *70/30 = 70% NPH, 30% Regular *50/50 = 50% NPH, 50% Regular *75/25 = 75% insulin lispro protamine suspension, 25% insulin lispro injection (rDNA origin) *Advantage - avoids errors from mixing Exenatide [Byetta] *MS page 919 *Incretin mimetic *Increases glucose-dependant insulin production *Suppresses elevated glucagon *Slows gastric emptying *Type 2 [w/ oral med] *Injectable *Supplied in prefilled pen *Fixed dosing for all pts. *Within 1 hr. before morning & evening meals *Nausea, vomiting most frequent SEs Exubera - Inhalable Insulin

*Within 10 min. before meals *Smoking is a contraindication *Increased hypoglycemia risk *Severe chronic lung disease is a contraindication *Causes small decline in pulmonary function *Hypoglycemia is most frequent adverse effect *? Still being produced - reported that Pfizer stopped production January 2008 dt low demand for drug *Goals of treatment *Self care agency Type[s] of insulin used depends on

Insulin Pumps *MS page 919 *Closest to normal pancreatic function *Continuous SQ infusion @ basal rate[s] *Bolus dose for meals *Regular or Humalog Insulin - Pen or Jet Injector Drugs That Increase or Decrease Hypoglycemia Effect of Insulin Iclicker Question A female client is on a sliding scale to control her diabetes. At lunchtime, her blood glucose is 200. She requires insulin. Which type of insulin should be given with her sliding scale? *Regular *NPH *Lente *Ultra Lente Iclicker Question After giving a female client her insulin per the ordered sliding scale, you would assess her for symptoms of: *Hypoglycemia in 2 hours. *Hyperglycemia in 3 hours. *Diabetic ketoacidosis after 4 hours. *Pre-diabetes after 6 hours. Case Study # 4 Type 1 Diabetic A middle-aged female with Type 1 DM who takes Humalog insulin before each meal per sliding scale and Lantus insulin every evening is planning a trip to visit her family in Europe. *What assessments/concerns would be important to discuss with this client? *What travel tips would you give this client? *What concerns would you have for her insulin therapy? *SBAR this situation. *Develop a concept map. ORAL Hypoglycemic Agents (OHAs)

*MS page 920 *Sulfonylureas *Starch blockers *Insulin sensitizers *Biguanides ORAL Hypoglycemic AGENTS (OHAs) Sulfonylureas *Stimulate pancreas to secrete insulin *Risk for hypoglycemia if inadequate food intake *Drugs: glipizide [Glucotrol], glyburide [DiaBeta, Micronase], repaglionide [Prandin] Sulfonylureas *Drugs = Glipizide (Glucotrol), Glyburide (DiaBeta, Micronase). Chlorpropamide (Diabenase) *Class: oral hypoglycemic & sulfonylureas *Action: stimulates pancreatic insulin production *Indication: Type 2 diabetes *Nursing: BG; give before or w/ meal; hold if pt. not eating; S/S hypoglycemia; for allergy to sulfa, can cause weight gain Starch Blockers *Drugs = acarbose [Precose], miglitol [Glyset] *Class: alpha-glucosidase inhibitor *Action: inhibits CHO absorption from GI tract *Indication: Type 2 diabetes *Nursing: BG; Give w/ first bite of food; may cause bloating, flatulence Insulin Sensitizers *Drugs = rosiglitazone [Avandia] & pioglitazone [Actos] *Class: insulin sensitizer *Action: increases tissue sensitivity to insulin *Indication: Type 2 diabetes *Nursing: LFTs, dec. H & H, wt. gain, dose of other oral hypoglycemia agent may need to be decreased Liver Inhibitor *Drug: Metformin [Glucophage] *Class: biguanide *Action: primary: inhibits liver glycogen breakdown to glucose-also increases cellular uptake of glucose *Indication: Type 2 diabetes; may be sole agent, or combined w/ other drugs *Nursing: must be dcd 48 hrs. before X-ray studies w/ iodine contrast & when pt. Dehydrated [possible kidney toxicity]; Cr. Newer Drugs - $25 billion / year worldwide

Iclicker Question Which of the following statement/s about oral hypoglycemic agents is/are true? (Select all that apply.) *Most should be given in the morning or AC or with meals. *Some such as glipizide (Glucotrol) or glyburide (DiaBeta, Micronase) contain sulfa so need to check for sulfa allergy. *Some can cause hypoglycemia if inadequate food intake. *The ingestion of alcohol with some can cause hyperglycemia. Case Study # 5 Type 2 DM on OHAs A middle-aged male who is obese and has Type 2 DM takes Metfomin and Actos daily. His LDL is 200 and his HLD is 45. His HbA1c is 9. *What are your concerns re this client? *What other assessments would you like to view? *What recommendations do you have for this client? *What patient teaching would you provide? *SBAR this client. *Develop a concept map. Quiz Time *Turn off cell phone. *Need one green scantron, pencil, eraser and iclicker. *Please put all your personal belongings in your backpack including cell phones and water bottles. *Please put your backpack in the front of the room. *On your scantron, legibly write your name, todays date, NRV 51, Quiz # ___, Diabetes Mellitus *Turn on your iclicker when the quiz begins. *Take a deep breath and think positive, *Scantrons will be passed forward to instructor before test review begins. *Test review will begin as soon as quiz is finished.